1902042781 NPI number — DR. KAREN JULIE MCKIBBIN PSY.D.

Table of content: DR. KAREN JULIE MCKIBBIN PSY.D. (NPI 1902042781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902042781 NPI number — DR. KAREN JULIE MCKIBBIN PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKIBBIN
Provider First Name:
KAREN
Provider Middle Name:
JULIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902042781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10300 SW GREENBURG ROAD, SUITE 240
Provider Second Line Business Mailing Address:
PORTLAND AUTISM CENTER, LLC
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-5410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-593-3331
Provider Business Mailing Address Fax Number:
503-206-7596

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10300 SW GREENBURG RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-5410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-593-3331
Provider Business Practice Location Address Fax Number:
503-206-7596
Provider Enumeration Date:
12/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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